Inside Health

Annual Physical Checkup May Be an Empty Ritual

By GINA KOLATA

Published: August 12, 2003

To the growing numbers of medical experts who preach evidence-based medicine -- the discipline that insists on proof that time-honored medical practices and procedures are actually effective -- there is no more inviting target than the annual physical.

Checkups for people with no medical complaint remain the single most common reason for visiting a doctor, according to surveys by the Centers for Disease Control and Prevention. In 2000, they accounted for about 64 million office visits, out of 823.5 million visits over all. At $120 to $150 per visit (and $2,000 or so for the gold-plated ''executive physical'' that many companies offer to top executives), that adds up to more than $7 billion a year.

Yet in a series of reports that began in 1989 and is still continuing, an expert committee sponsored by the federal Agency for Healthcare Research and Quality, an arm of the Department of Health and Human Services, found little support for many of the tests commonly included in a typical physical exam for symptomless people.

It found no evidence, for example, that routine pelvic, rectal and testicular exams made any difference in overall survival rates for those with no symptoms of illness.

It warned that such tests can lead to false alarms, necessitating a round of expensive and sometimes risky follow-up tests. And even many tests that are useful, like cholesterol and blood pressure checks, need not be done every year, it said in reports to doctors, policy makers and the public.

But if the annual physical is largely obsolete, hardly anyone has gotten the message. While the federal Medicare program does not pay for routine checkups -- by law, it is limited to treating illness -- many insurance companies do, saying their customers continue to demand them. Many doctors say they perform them out of habit or out of a conviction that patients expect them and that they help establish trust.

Even doctors who know all about the evidence-based guidelines for preventive medicine say they often compromise in the interest of keeping patients happy. Dr. John K. Min, an internist in Burlington, N.C., tells the story of a 72-year-old patient who came to him for her annual physical, knowing exactly what tests she wanted.

She wanted a Pap test, but it would have been useless, Dr. Min said, because she had had a hysterectomy. She wanted a chest X-ray, an electrocardiogram. Not necessary, he told her, because it was unlikely that they would reveal a problem that needed treating before symptoms emerged. She left with just a few tests, including blood pressure and cholesterol.

Dr. Min was proud of himself until about a week later, when the local paper published a letter from his patient -- about him. ''Socialized medicine has arrived,'' she wrote.

Admitting defeat, he called her and offered her the tests she had wanted, on the house. She accepted, Dr. Min said, but after having the full physical exam, she never returned.

Proponents of evidence-based medicine acknowledge that repeated tests like chest X-rays, electrocardiograms, rectal exams, pelvic exams, urinanalyses and blood work do occasionally find problems before symptoms emerge. But that does not make them necessary or even advisable, said Dr. David Atkins, the science adviser to the United States Preventive Services Task Force, an independent panel of experts that advises the Agency for Healthcare Research and Quality.

For example, Dr. Atkins said, urinanalysis can detect bacteria in the urine of 5 to 10 percent of women who have no symptoms of bladder infection. But when such patients were studied, it turned out there was no difference in the outcomes between women given antibiotics and those given placebos.

Although the bacteria disappeared in most women's urine after they began taking antibiotics, they often came back after the drugs were stopped. In the end, just as many patients in each group ended up with symptomatic bladder infections. The only difference was that the group of women who took antibiotics early on had more side effects.

Other tests are superfluous for other reasons. Feeling the ovaries in a pelvic exam is not a good way to find ovarian cancer, according to the Agency for Healthcare Research and Quality and the American College of Physicians; by the time a tumor can be felt, the cancer is probably too advanced for treatment to help. Not finding anything is not necessarily reassuring because small tumors cannot be felt anyway, the group adds.

Nor is there any need for a doctor to take out a stethoscope every year and listen to your heart, to thump your chest each year or look into your eyes, ears and throat. Those time-honored procedures provide no medical benefit for the healthy patient with no symptoms, said Dr. Paul Frame, a member of the task force who has examined evidence for these procedures.

Many doctors do a careful physical exam on a patient's first visit, to serve as a baseline, but on subsequent visits, groups like the Agency for Healthcare Research and Quality say, patients would be better off if doctors spent their time counseling them on such things as stopping smoking, eating a healthy diet and drinking moderately, using seat belts and having working smoke alarms in their houses.